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Abstract

Traumatic brain injury (TBI) is a significant problem in the pediatric population. Ninety per cent of pediatric TBIs present to an emergency department, but only 8% are hospitalized. Since the majority of pediatric patients with mild TBI are therefore discharged home with the diagnosis of concussion, accurate assessment of the severity if concussion and consequent outpatient management and instructions are critical for ensuring safe recovery from injury. Without state of the art knowledge and clinical tools, mild TBI (mTBI) may go undiagnosed and untreated, leaving individuals who have sustained a mTBI with an increased risk for functional problems. The ACE and ACE care plan were developed as part of the CDC’s “Heads Up: Brain Injury in your Practice” toolkit for physicians to manage mTBI. Adapting the ACE for the ED and implementing a standardized clinical protocol by ED physicians systematically should improve management by ensuring accurate diagnosis and improving patient education and adherence with discharge recommendations. The goal of this research is to demonstrate the capacity to improve diagnosis and management of mTBI presenting to the Emergency Department (ED) by the feasible application of systematic procedures in the form of the ACE and the ACE Care Plan. This study will be conducted collaboratively by Children's National Medical Center and UPMC/ Children’s Hospital of Pittsburgh with the specific aims to: (1) evaluate the feasibility of the ACE and ACE Care Plan for standardized implementation in the ED setting (2) determine if the ACE and ACE ED Care Plan can be implemented by the ED staff and disseminated to the Primary Care Providers and (3) determine if routine use of the ACE ED and ACE ED Care Plan will improve patient/family follow up behavior and patient recovery. We have designed the study to progress in two stages: Stage 1 proposes to develop expert consensus agreement regarding the importance and feasibility of using the ACE and ACE Care Plan in the ED setting, including an understanding of current concussion management care pathways. An outcome of Stage 1 will be the consensus based adaptation of the ACE and ACE Care Plan for the ED, referred to as the ACE ED and the ACE ED Care Plan. Stage 2 applies these revised tools via a pilot implementation study for patients age 5 22 years old presenting with mTBI. The primary outcome will be patient/family follow up behavior with the primary care/specialist. As secondary outcomes, we will examine clinician adherence to use of the ACE ED and ACE ED Care Plan, and its dissemination to primary care providers. Feasibility of implementation will be further evaluated by identifying the actual facilitative and barrier conditions to ACE ED/ Care Plan use within the ED setting. We will also develop estimates of effect of this implementation on patient recovery.